Lecture 19 parekh non insertional and insertional achilles tears
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This document discusses insertional and noninsertional Achilles tendonitis. It begins by covering the etiology, pathophysiology, and classification of the conditions. Histopathologically, it can present as paratenonitis, paratenonitis with tendinosis, or tendinosis. Symptoms include pain, swelling, and impaired performance. Nonsurgical treatments discussed include rest, bracing, exercises, shockwave therapy, and various injections. Surgical management is considered for recalcitrant cases and involves debriding degenerative tissue and potentially augmenting the tendon with a transfer. Post-operative rehabilitation protocols are also outlined.
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Lecture 19 parekh non insertional and insertional achilles tears
- 1. Insertional and Noninsertional Achilles Tendonitis Selene G. Parekh, MD, MBA Associate Professor of Surgery Partner, North Carolina Orthopaedic Clinic Department of Orthopaedic Surgery Adjunct Faculty Fuqua Business School Duke University Durham, NC 919.471.9622 http://seleneparekhmd.com Twitter: @seleneparekhmd
- 2. Etiology
- 3. Etiology • Intrinsic factors of note: • HTN • Diabetes • Obesity • Exposure to steroids/estrogen • Advancing age • Exposure to quinolones • Variants in gene of MMP-3
- 4. Pathophysiology • Cellular & molecular response to microscopic tearing chronic degenerative process • Incr # tenocytes • Incr concentration GSG • Disorganized/fragmented collagen • Neovascularization • Incr concentration glutamate • Incr concentration lactate
- 5. Classification • Histopathologic • Paratenonitis • Paratenonitis with tendinosis • Tendinosis
- 6. Classification • Paratenonitis • Definition • Inflammation of only the paratenon, either lined by synovium or not • Histo • Inflammatory cells in paratenon/peritendinous areolar tissue • Clinical • Warmth, edema, tender • Paratenon thickened and adhered to normal tissue
- 7. Classification • Paratenonitis w/ tendinosis • Definition • Paratenon inflammation w/ intratendinous degeneration • Histo • Same as paratenonitis w/ loss tendon collagen, fiber disorientation, scattered vascular ingrowth • Clinical • Same as paratenonitis w/ nodule
- 8. Classification • Tendinosis • Definition • Intratendinous degeneration w/ atrophy • Histo • Noninflammatory intratendinous collagen degeneration, fiber disorientation, hypocellularity, occasional necrosis and calcification • Clinical • Often nodule in nontender, little edema
- 9. Classification • Duration symptoms • Acute < 2 wks • Subacute 3-6 wks • Chronic > 6 wks • Insertional vs. noninsertional
- 10. Presentation • Symptom triad • Pain • Swelling • Impaired performance
- 11. Presentation •Physical exam •Pain/tenderness @ Achilles •Morning pain, increases w/ usage •Pain will progress from activity-related to constant •Fusiform swelling
- 12. Presentation •Physical exam •Pain/tenderness @ Achilles •Morning pain, increases w/ usage •Pain will progress from activity-related to constant •Fusiform swelling
- 13. Presentation •Peritendinitis •Tendon normal •Peritenon thickened, fluid, adhesions •Tendinosis •Tendon thickened, nodular, softened, yellow, & degenerated
- 14. Imaging • X-ray • Calcifications • Haglund’s deformity • “Pump bump” • Parallel pitch lines
- 15. Imaging • Plain radiographs • Calcification
- 16. Imaging • Plain radiographs • Calcification • MRI • Helpful to evaluate extent of disease • AP diameter < 6mm • US • User dependent
- 17. Nonsurgical Treatment • Rest and activity modification • AFO/shoe inserts/casts/night splints • 2-6 weeks • No studies demonstrate the efficacy of rest
- 18. Nonsurgical Treatment • Ultrasound • Rat study suggest stimulation of tenocyte migration • No well designed studies show support of use
- 19. Nonsurgical Treatment • Low level laser therapy • May increase collagen production, down regulate MMP, decrease capillary flow of neovascularization • 2 studies • Decr pain: rest, activity, palpation • Decr immediate pain threshold • Insufficient evidence to support usage
- 20. Nonsurgical Treatment • Eccentric/Concentric exercise therapy • Decrease neovascularization • Tensile force temporary ceases blood flow repetition neovessels obliterated w/ pain receptors • Studies • Improved pain @ 12 weeks (2) • Structural and compositional changes • Resolution of structural anomalies • Decr tendon thickness
- 21. Nonsurgical Treatment • Eccentric/Concentric exercise therapy • Studies • Eccentric vs concentric exercises (4) • Eccentric exercise does not offer significant decrease in pain over concentric exercise • @ 12 wks: eccentric patients more satisfied and return to activities • Specific role in treating noninsertional Achilles tendonitis unclear
- 22. Nonsurgical Treatment • Shockwave therapy (SWT) • High energy eliminates pain • Stimulating soft tissue healing, regenerating tendon fibers, inhibiting pain receptors • Studies (4) • Low energy (3), differing doses, short f/u, small cohorts • Insufficient evidence to support SWT: most effective dose and duration unknown
- 23. Nonsurgical Treatment • Glyceryl trinitrate • Prodrug of NO • Increase fibroblast collagen synthesis • Topical transdermal treatment over point of maximal tenderness • Studies • Decr tenderness, night pain, activity pain, and improved functional outcomes • No changes in neovascularity, wound fibroblasts, collagen synthesis, NO production • 20% discontinue treatment due to headaches • Conflicting evidence of efficacy
- 24. Nonsurgical Management • Corticosteroid injection • Decr pain • Decr tendon thickness • Intratendinous injection concerns re: catabolic effects on the tendon • Evidence of usage is insufficient. Concerns re: rupture outweighs its usage.
- 25. Nonsurgical Management • Platelet rich plasma therapy (PRP) • Delivery of hyperphysiologic doses of cytokines • Some success HSS/Baltimore • Evidence of usage is insufficient.
- 26. Nonsurgical Management • Sclerosing injections/Prolotherapy • Polidocanol • Thrombosis of vessels and destroys nerves • Proliferation of fibroblasts • Synthesis of collagen possible remodeling of tendon • 25% dextrose solution • Dehydrate cells influx inflammatory cells tendon healing • Poor evidence to recommend usage
- 27. Nonsurgical Management • Aprotinin injections • Collagenase inhibitor • Can have systemic allergic reactions • Studies • RCT: no difference than placebo injection • Insufficient evidence to recommend usage
- 28. Operative Management • Used for recalcitrant cases • 3-6 months of conservative treatment • Goals • Resect calcaneal bone • Resect degenerative tissue • Augment tendon if needed • >50%
- 29. Operative Management • Percutaneous longitudinal tenotomy • Mild/moderate disease • 67-97% success rates • Worse outcomes: • Multinodular disease • Severe disease • Paratendinopathies
- 30. Operative Management • Minimally invasive stripping • Large diameter sutures passed through stab incisions • Slide anterior to tendon to strip it • No studies to show efficacy
- 31. Operative Management - I • Excision of Haglund’s deformity • Position • Prone vs. supine • Incisions • Lateral, medial both, or central • Inflamed bursa excised • Enlarged tuberosity resected • Tendon transfers • FHL (Wapner) • Better length than FDL • Better biomechanics than FDL
- 32. Operative Management - I • Prone • Central, Achilles tendon splitting approach • Elevate 70-80% of tendon insertion • Resect Haglund’s check on fluoro
- 33. Operative Management - I • Debride Achilles • < 50% involvement • Anchors into calcaneus • Tie Achilles • Close Achilles split
- 34. Operative Management - I • Debride Achilles • > 50 % involvement single incision technique • Open deep fascia and find FHL muscle belly • Find FHL tendon and trace into canal • Plantarflex ankle and toe and pull on tendon • Release tendon • Drill hole anterior to Achilles insertion • Pass FHL tendon and screw • Repair Achilles insertion, split and skin
- 35. Operative Management - I • Debride Achilles • > 50 % involvement double incision technique • Medial foot approach and find knot of Henry • Release FHL • Open deep fascia and find FHL muscle belly • Find FHL tendon and trace into canal • Pull FHL tendon through • Create 2 drill holes: one anterior to Achilles insertion and one medial to lateral • Pass FHL tendon and tie to self
- 36. Operative Management - NI • Debridement with/without tenosynovectomy • Moderate/severe disease • Debride all tendinopathic tissues • <50% • +/- tubularization • >50% • FHL transfer (single/double incision) • Studies • Improved pain, functional outcomes, • Fair evidence supports treatment
- 37. Post-Op Protocol • No Tendon Transfer • NWB in Bulky Jones splint x 2wks • SLNWBC x 2 wks • SLWBC x 2 wks • Tendon Transfer • NWB in Bulky Jones splint x 2wks • SLNWBC x 4 wks • WB CAM boot x 4 wks, start PT
- 38. Operative Management •Complications •11% rate •1 year f/u •Satisfied w/ outcomes •Return to activities •Skin edge necrosis •Superficial/deep infections •Seroma/hematoma formation •Sural neuritis •Partial ruptures •Sensitive/hypertrophic scars •Weakness of plantarflexion
- 39. Incision
- 44. Debride Tendon
- 46. Drill Hole Anterior to Achilles
- 47. Pass Tendon
- 48. Anchors
- 49. Tie Tendon
- 50. Close Tendon